What skills should be assessed in doctors' performance appraisals? One trust came up with a wide range of skills and competencies when it surveyed senior clinicians and managers. June Goodson-Moore and colleagues report

The performance review and appraisal of both the clinical and non-clinical aspects of doctors' work is now firmly on the agenda. But it is not clear what management competencies should be considered. What management skills do doctors need to make them truly effective, and how should these be assessed?

While it is accepted that clinical skills are of paramount importance to clinicians, the broader array of non-clinical skills they require cannot be ignored. Senior clinicians, in particular, need to be more than just good clinicians . They need to work effectively with other members of their own team, with other multidisciplinary teams, with patients and their families, and with nursing staff, managers, directors and the wider community.

Non-clinical skills

In managing themselves and their staff, senior doctors need to be leaders, organisers, planners, strategists, networkers, sometimes counsellors, educationalists and even examiners.

While it is accepted that clinical skills are essential for any clinician, they are maintained and measured by continuing medical education and revalidation; they are not the main target of personal appraisal for doctors.

Assessing and developing the broader array of non-clinical skills needed by doctors cannot be ignored and, indeed, is a key component of the appraisal process. Poor clinicians probably remain poor clinical performers, however good their non-clinical skills are. But good clinicians can certainly become truly excellent if they can be more effective in their non-clinical roles too.

Pinderfields and Pontefract Hospitals trust, West Yorkshire, has recently engaged its own senior clinicians, ward managers and other managers in the debate about just what does make a good doctor, especially in the imprecise area of non-clinical skills and qualities.

The trust employs more than 4,500 staff in five hospitals, with a turnover in excess of£116m.Formed in 1997 as a merger of two large hospitals in Wakefield and Pontefract and three smaller ones, it offers both acute and specialist acute services to a demanding population.

The trust decided that if good practice could not be defined and agreed in the area of non-clinical skills and behaviours, it would be unreasonable (if not impossible) either to assess or develop them. It felt that if non-clinical skills and behaviours could be defined fairly and objectively, they could be used as benchmarks for appraisal, for guidance on the future development of clinical staff and as a yardstick for future recruitment.

The project

To find out what excellent clinicians need to do in the non-clinical aspects of their activities, and how they manage themselves and others, the trust engaged management consultants Quantum Enterprise Development (QED). Its team interviewed more than 60 senior clinicians, managers and directors in the trust, as well as a patients' participation group, in strict confidence. These interviews used behavioural-enquiry methods such as critical incident techniques to establish the desired 'competencies' - the personal skills and qualities that distinguish the non-clinical skills of outstanding senior clinicians from others.

Before starting the project, detailed discussions were held with the trust's director of human resources, assistant director of human resources and medical director. The aim was to explain how the project would benefit and relate to the medical staff appraisal process under development by the trust, and to anticipate any likely concerns.

These included the time needed for each interview, nervousness about 'yet another survey', and concerns about confidentiality. The director of human resources and medical director made a presentation to a senior medical staff committee meeting, where the project received support.

One-to-one private interviews lasting two hours were held at the trust during March, April and May 2000.Group interviews were held towards the end to review the initial summary of results. The focus was specific. What is it that outstanding performers actually do? How do they behave?

What do they say - or not say? What makes them so special?

The results

Each group interviewed tended to have a different focus.

Ward managers and patients naturally concentrated on senior clinicians' behaviour on the ward and in clinics, managers tended to focus more on organisational and planning issues, while the senior clinicians themselves were particularly alive to the degree of cultural and political change in the NHS, and working within national policy guidelines and ever more stringent financial constraints.

A clear thread of common competencies emerged from the interviews (see box).

With in each area detailed indicators of good and unacceptable behaviour were drawn up, ranging from 'building bridges and links with decision-makers' to 'learning from others' experience', 'knowing when to make a decision and when to wait', 'facilitating learning from mistakes and complaints', 'not taking questions as a personal challenge' and 'maintaining patients' dignity, even when under anaesthetic'.

What next?

The next step is to explain the results of the work using briefing meetings and committees involving senior clinicians at the trust. This needs to be part of the trust's mainstream development agenda and not just a one-off activity. All the senior clinicians, whether they were involved in the detailed interviews or not, will now be invited to comment and amend the initial results as they see fit through a confidential postal questionnaire. This will be managed by QED away from the trust.

They will also be asked to rank both the broad competencies and each indicator within that competence according to importance and relevance to them. For example, some of the patient-facing skills and behaviour may be less relevant to diagnostic clinicians who have less direct contact with their patients. However, it is anticipated that the behaviour that affects colleague relationships, such as respect, communication and listening skills, will apply just as much.

Pinderfields and Pontefract Hospitals trust now has a detailed statement of the preferred personal qualities and skills of senior clinicians, drawn from its own team, reflecting the trust's own specific culture and organisational needs. By engaging all those involved, the trust's senior clinicians will take on board the results, and use them to appraise their own non-clinical performance and to determine appropriate ways forward for individual development and job enrichment. The results will also guide future recruitment strategies.

We have all been challenged in recent weeks by the modernisation agenda. If we are truly to modernise our professions, we must start to understand and develop the totality of their role and not just concentrate on the clinical agenda.

Key points

Consensus is needed on which management competencies should be included in doctors' appraisals.

One trust employed management consultants to find out the views of senior doctors, managers, directors and patients.

Common themes included concern for standards, effective use of information, openness, integrity and insight.

The results will be used to guide future recruitment.

Competencies considered valuable by those interviewed:

breadth of awareness of the structures, processes, policies and politics across the service, and commitment to the organisation and the service;

concern for quality and standards, seeking continuous improvement and being open to change and others' suggestions, while developing others, offering practical support and sharing their own expertise freely;

decisiveness and judgement, reviewing all the necessary information objectively, evaluating alternatives and taking timely action;

drive and direction, working hard and achieving results productively, being resilient to inevitable pressures and offering clear direction to others;

handling and managing information, thinking around issues, and identifying potential problems and solutions from the information collated;

integrity and insight, high standards of personal conduct, being self-aware and managing one's own impact on others, and respect for others' views, needs, skills, expertise and background;

teamwork and co-operation, working collaboratively and openly with a wide range of others to achieve agreed goals.